- Email: [email protected]
Uncovering fear: Group experience of nurses in a cancer ward
ooze-7480/S I/O201 -0047 $02.00/0
ht. J. Nurs. Stud. Vol. 18, pp. 41-52. 0 Pergamon Press Ltd., 1981. Printed in Great Britain.
Uncovering fear: group experience of nurses in a cancer ward LEA BAIDER, Ph.D. and SARAH PORATH, M.A. 41Ramban Street, Jerusalem, Israel.
Introduction In the twentieth century life expectancy has been extended. Youth, energy and initiative are idealized; achievement, success and progress represent important challenges. Few people permit themselves to indulge in thoughts about death. Naturally one tends to reject unpleasant and distressing thoughts. Any speculation on the subject of death is viewed as so fearsome that normally one blocks it out, and when death suddenly forces itself on us, so to speak, we are ill prepared to go through with the experience. The stigma attached to the dying cancer patient is familiar; nurses working on the cancer ward share the common attitude. Research studies carried out in the United States (Abrams, 1966; Olson, 1974; Hobbs, 1969) and in Israel (Antonovsky, 1972) have pointed to the fact that cancer is seen both as malignant and hopeless. There is a widespread notion that of all the causes of death it ranks highest and of course this belief provokes a good deal of anxiety. Studies in the U.S. (Holleb, 1975) and Israel (Antonovsky, 1972) have shown that women tend to delay going for medical checkups out of fear and anxiety concerning the possible diagnosis. Denial is also the most common defence mechanism of cancer patients about to die (Hackett and Weisman, 1964; Haan, 1977). Medical staff on the oncology ward, however, cannot use this mechanism. The staff come face to face with death on a daily basis. A nurse confronted with a dying patient has the problem thrust upon her and must find some way to cope with it. Lately, attention has been focused in the literature on the problems that arise in the treatment of terminal patients, particularly those with cancer (Feifel, 1977; Schoenberg, Carr, Peretz and Kutscher, 1970; 1972). In nursing, overall treatment of the patient and his family has been stressed, and aimed at helping him to regain a sense of mental and physical wellbeing. During her training, the student nurse encounters disease, pain, suffering, and the inevitability of death. For the nursing student, encounters with death are but passing episodes in the framework of clinical care and rehabilitation, and these usually take place when she is assigned to a ward of chronic or cancer patients. 47
48
LEA f3AIDER AND SARAH PORA TH
In nursing literature, the seriousness of the problem is recognized (Quint, 1967; Epstein, 1975). A conflict rooted in the conception of the nurse’s role is uncovered, revealing a wide discrepancy between the student nurse’s image of her future role and the function she performs in reality as she cares for terminal patients. As stated by Craytor et al. (1977): “A task unique to the nursing profession is to assist the individual in sickness or in health to independently maintain habits which contribute to good health or its recovery; functions which he would be able to perform without assistance if he had the strength, the willpower or the knowledge required; and to do this in a manner which would permit him to achieve independence as quickly as possible.”
The nurse in an oncology ward senses the unbridged gap which lies between her professional training and the inherent meaning of terminal patient care. Awareness that one cannot realize professional goals is a link in a chain of frustration hastening fatigue and all the accompanying manifestations of anger, aggression, malaise, and in the end, escape. The nurse feels helpless when relating to patients .who are about to die. The emotional problems she must face involve not only the patient but also his family, other staff members, and above all, herself. Unrelenting focus on patient needs is the hallmark of the nursing profession. This makes great emotional demands on the professional, added to the physical strain inherent in such a commitment. Researchers observing service-oriented professionals have found that the unceasing mental pressure. gradually exhausts the individual’s resources, interfering at times with daily functioning and even precipitating a more serious crisis (Maslach and Pines, 1978; Pines and Kafri, 1978; Maslach, 1976). This phenomenon can be seen in a variety of guises. The nurse may gradually lose interest in her job or even in the profession, transfer to a less ‘threatening’ ward, or drop out altogether. Those who do stay often develop feelings of resentment aimed at colleagues and a hostile attitude towards the patients. Rather than take initiative, assume responsibility, and manifest concern as she had once done, she evolves a very different attitude-submission: to routine, to indifference, to neglect. The framework of her job puts the nurse under stresses which may affect her performance: lowered standards, lateness and absenteeism, illness, and staff quarrels result as they serve to perpetuate the organizational pressures. Behavioural responses are mutually aggressive while levels of controlled and released anger rise. Symptoms of personal exhaustion develop. Thus, providing psychological support and feedback to nurses who work with dying patients is of vital importance for their emotional stability, professional motivation and performance, and awareness of the emotional complexity of their role. This conclusion was reinforced from several sources related to the first author’s work as a staff psychologist in the Oncology Department of Hadassah Hospital in Jerusalem: (1) individual contacts with the nurses of the Department, in which they spontaneously voiced their dissatisfaction, anger and frustration with their work; (2) the impression of the ward physicians that an unusually high level of tension existed among the nurses; (3) the realization that the nurses did not have any support for, or feedback from, their work in the Department; (4) personal conversations with the head nurse about the high turnover rate on the ward and also discussion of other ward problems. Group work with n&es
The first author therefore suggested to form a group to promote the following aims: to facilitate communication among the nurses themselves; to share, in a group context,
UNCOVERING
FEAR: GROUPEXPERIENCE
OFNURSES
INA
CANCER
WARD
49
the common experiences of the nurses, i.e. dealing with cancer patients and with the pressure of work; and, most important, to unmask the nurses’ fears about death and expose the paradox of nurses who know they cannot cure their patients. In 1977-78, 20 group sessions were held, led by the first author as a psychotherapist, assisted by a senior psychiatric nurse (the second author). The sessions were held in the Oncology Ward of Sharett Institute, part of the Hadassah University Hospital. On the average, 6 nurses, 3 of whom are registered, care for 30 inpatients. The patients stay on the ward anywhere between 2 weeks and 5 months; relapsed cases are readmitted to the ward for additional treatment. There are no restrictions on family visits. The patient’s family may eat and even sleep on the ward. As a result, the nurses get to know not only the patient but often the entire family. From November 1977 to June 1978, we met weekly on a regular basis. The time was adjusted to fit the work schedules of the nurses. There were no meetings on holidays. Each session lasted from one to one and a half hours. Nurses raised the issues and the leaders acted as facilitators for open discussion, supporting the nurses when they expressed intense feelings or manifest pain. We dealt mostly with day-to-day matters produced by the work situation while emphasizing those hidden elements in interactions that one tends to overlook. We decided at the onset to meet for about 6 months. An average of six nurses took part in the meetings, though the number varied from four to twelve in any given session. Group process Inception. Making use of the group process, we attempted to show the nurses how they tried to protect themselves from the feelings of anger, fear and frustration brought on by the contradictory nature of their role. The oncology nurse must adjust her function, shifting the emphasis from cure to care, and realize that even care may provide only partial relief from suffering, not its remedy. At the onset, the group identified two discrete approaches to the nurse’s role. The ‘old’ nurses (who had been on the job for one or more years and included two nurses with 8 and 12 years’ experience) approached their work on the ward pragmatically, claiming that only if they neutralized their expressive-affective reactions could they hope to function adequately in the anxiety-provoking, frustrating and threatening environment referred to as the ward. The ‘new’ nurses (new on the job and/or in the country) maintained that in the absence of cure, technical efficiency as a criterion for good performance was out of place and felt that the emphasis ought to be on seeking expressive modes for relating to the dying patient, though such an open and vulnerable position involved real psychological hardship. At the same time, all the nurses accompanied this clear-cut distinction with a common expression of anger and isolation, and felt that they were unable to share their highly emotional but frustrating experiences with one another. The new nurses attributed the overwhelming emotional experience to insecurity and lack of experience and so were ashamed to share it with the other nurses. The old nurses, similarly inhibited, judged their emotions inappropriate in the well-trained, efficient nurse. Both groups of nurses felt alienated and alone. New nurses saw the more experienced nurse as distant, even arrogant, and not to be approached. They described what they did with their built-up tension, how they let it out on their families after work and so extended their work-related frustrations to the home sphere.
50
LEA BAIDER AND SARAH PORA TH
The durses also sought an external target for their mounting anger and found that certain staff members, a type of patient, rules and regulations were easy prey. Most of the time they could not justify their rage objectively, as it stemmed from the subjectively felt isolation and fear that pursue nurses at work. Attempts to externalize anger were followed in the sessions by an emphasis on open discussion of death-that of the patient and their own. This shift occurred once the first phase, which lasted about two months, had ‘legitimized’ free expression of the forbidden feelings of anger and fear. The nurses showed ambivalence in their reaction to patients’ imminent death, alternately approaching and avoiding contact. Every encounter with the patient or his family was like looking death in the face and induced avoidance behavior-until the next time. Subsequent encounters increased the nurses’ involvement and identification with the patients and with the families undergoing anticipatory mourning. It became more and more difficult for the nurses to separate professional roles and private feelings. As one nurse explained: “I could not just go on with the daily routine, giving infusions and taking his pulse, his temperature, blood counts. He always smiled and had an encouraging word for me. Can you imagine? He was trying to lift my spirits, make me feel that I could really help him. Every time I left his room I started to cry; not for him but because I saw how powerless I was, and out of fear. I never told this to anyone. I met his whole family, wife, four children, and other members of the family who came to visit. I talked with them as if they had been my own family. When there wasn’t too much to do on the ward, I would take the children for walks around the building or in the grounds. Afterwards, Mr. P. couldn’t hear enough about our outing and wanted to know every detail. especially about his children. The best times with him were when the ward was quiet. Then I spent a long time with him and he told me about his youth, work, hopes; not once feeling sorry for himself. He knew he was dying. I am sure that he knew, but I could not bring myself to discuss it with him. I was afraid and I didn’t know what I should say. Then I tried not to think about it, to take my mind off the subject. When he died I asked for three days off. I had terrible nightmares and felt so angry and lost that 1 didn’t want to go back to work ever again.”
Many nurses repeatedly expressed their feelings of anger and frustration at ‘losing’ the patient, as if the patient had been a part of their internal love-object. This feeling was followed by one of emptiness and depression, as they questioned the nature and doubted the significance of their own nursing roles. Thus, helplessness replaced direction. At this point the nurses began to speak of being afraid of their own deaths. Rather than focus on the introjection of the patients’ deaths, they directed their attention to the problem of introjection as it related to their own mortality. Nurse A: “When I started to work on the ward I had terrible dreams. I saw what death was. I was taken by force to dark and desolate places where there weren’t any people or other living things, and my voice had no sound. I used to wake up screaming. My room-mates told me to go see someone for help but I was embarrassed and didn’t want to talk about it.” Nurse B: “I also had nightmares. I don’t remember them very well; dreams with people I didn’t know. I cried a lot too, knowing each of them was going to die. I thought that perhaps they were patients, though I couldn’t recognize them. On the ward I looked into the patients’ rooms to see if I could recognize any of them from my dreams, but 1 didn’t. It was really strange, and I was very scared.” Nurse C: “I think we all experience this in one way or another, in this line of work. For me, whenever a patient was dying, I imagined how I might feel or react in his place. Even though I always push such thoughts from my mind, I kept catching myself thinking about my own death. I used to think of it as the unspoken curse of life, something that I couldn’t share with anyone. My family and friends think I’m crazy to be working with dying people. They say that it is enough we live in a country where death is all around us.” Nurse D: “it’s true; my friends and family say the same thing, but 1 see a difference. I am not afraid to get on a bus or pass through Zion Square. 1 don’t think about death. But being here and seeing all the patients suffering, day in and day out, and knowing that they will die in any event, makes me not want to suffer, not want to die.” Nurse E: “But there is a difference. In one case it is a hero’s death, you see. In the other case death comes from a disease that people pretend doesn’t even exist.”
UNCOVERING FEAR: GROUP EXPERIENCE OFNURSES INA CANCER WARD
51
This prompted the nurses to exchange common experiences, personal confrontations with death, their own reactions to the deaths of relatives and friends. It was noted that one reason some nurses work in the Oncology Department is to overcome the fear of their own death. Slowly, the group developed a sense of togetherness, mutual caring and sharing. Nurses were caring and open about one another’s experiences. Death, it was felt, was no longer an isolated, individual, shameful thing, but the reality of all. The nurses had to tackle it on the practical level, and cope with it psychologically every day. This growing sense of mutuality gave the group solidarity and cohesion. For the first time the nurses could talk openly about the real difficulties of their work and the best means for coping with them. Now the group could face the constant pall of death’s approach in a realistic way, as part of their daily work. Of course this optimism was unrealistic as well. Essentially the problem was an integral part of their work. The simultaneous wish to cure and to escape could not be resolved. With all, the group gained insight, and respect for the manifold approaches to death. Termination. Meetings were discontinued about 7 months after they had begun, chiefly for administrative reasons. Many nurses left the Department, the group leader was away temporarily, work pressure mounted. Despite this, a more positive, warm, cooperative atmosphere grew among the nurses. After the break, the nurses were reluctant to resume group meetings because of an objectively heavier work load with fewer nurses on the ward, and a subjectively felt need for a breather from the tough issues faced in the group sessions. Little doubt remains that such a stressful work situation demands a steady, supportive framework within the Department. Other professional groups working with inpatients could effectively provide this support (i.e. doctors, social workers, physiotherapists, etc.). Though the nurses were left with a sense of security and protection from the group solidarity which had developed over the last few months of the sessions, this cannot fully counteract the persistent, wearing effect of death on the performance of their professional roles. The nurses wondered whether the physicians had similar feelings; this implies that they had a strong need to understand how doctors cope with the situation. More overt communication between medical professionals can therefore lead to better, more truthful, ways of handling the stresses of their work. Many issues were not even mentioned by the group or were alluded to only by implication. Among these were the matter of competition between nurses and doctors, and among the nurses themselves. Discussion of other nurses’ and doctors’ deaths was avoided, pointing to the nurses’ own continued vulnerability. Avoidance or denial of certain issues implies the urgent need to work through the feelings involved, and each nurse must find her own best way to deal with these issues. Greater cooperation on the part of the administrative sector of the Department is also essential. Conclusion Studies indicate that in frameworks in which the staff received support from colleagues in staff meetings and through controlled staff turnover, they related to the patients more positively, gained confidence in their roles, and were more consistent. Group sessions were particularly useful in helping the staff to socialize, to consult one another, to give vent to their anger and aggression, and to work as a unit (Maslach and Pines, 1979).
52
LEA BAIDER AND SARAH PORA TH
Studies of nurses’ conception of the cancer patient (Crayton et al., 1977) have recommended a revision of the study programs, a change in attitude, and greater willingness on the part of the nurses to face terminal patients. The stark reality that nurses encounter when working with terminal patients requires a total re-evaluation of their task, geared not to curing, but rather to improved care. Training, supervision, and group or individual support must provide them with the feedback and stimulation necessary to appreciate and go on with their unique, valuable work. References Abrams, R. D. (1966). The patient with cancer: his changing pattern of communication. New Engl. J. Med., 274. Antonovsky, A. (1972). The image of four diseases held by the urban Jewish population of Israel. J. chron. Dis. Crayton, K., Morrow, R., Brown, J. and Fass, M. (1977). A study of nurses’ views and perceptions related to cancer care, cancer patients and cancer nurses. University of Rochester, New York (unpublished). Epstein, C. (1975). Nursing and the Dying Patient. Prentice Hall, Englewood Cliffs. Fiefel, H. (1977). New Meanings of Death. McGraw-Hill, New York. Haan, N. (1977). Coping and Defending. Academic Press, New Yom. Hackett. T. P. and Weisman, A. (1964). Reactions to the imminence of death. In The Threat of Impending Disaster. Grosser et al. (Eds.). M.I.T. Press, Cambridge. Henderson, V. (1966) The-Nature of Nursing. MacMillan, New York. Hobbs, P. (1969) Merseyside survey of public opinion on cancer. Med. Officer, 121. Holleb, A. I. (1975). Women’s attitudes regarding breast cancer: results of the Gallup Poll. In Early Breast Cancer: Defection and Treatment. H. G. Gallather (Ed.). John Wiley, New York. Kafry, D. and Pines, A. (1978). The Experience of Tedium in Life and Work. The University of California, Berkeley. Maslach, C. (1976). Burn out. Humon Behav. 5. Maslach, C. and Pines, A. (1978) Burn out: the loss of human caring. In Experiencing Social Psychology, A. Pines and C. Maslach (Eds.). Random House, New York. Olson, K. (1974). Cancer and the patient. Ann. intern. Med. 81. Quint, J. C. (1967). The Nursesand the Dying Patient. MacMillan, New York. Schoenberg, B., Carr, A., Peretz, D. and Kutscher, A. (Eds.) (1970). Loss and Grief: Psychological Mmagement in Medical Pructice. Columbia University Press, New York. Schoenberg, B., Carr, A., Peretz, D. and Kutscher, A. (Eds.) (1972). Psychotogicut Aspects of Terminal Cure. Columbia University Press, New York. (Received 2.4 June 1980; acceptedforpublication
30 June 1980)
ht. J. Nurs. Stud. Vol. 18, pp. 41-52. 0 Pergamon Press Ltd., 1981. Printed in Great Britain.
Uncovering fear: group experience of nurses in a cancer ward LEA BAIDER, Ph.D. and SARAH PORATH, M.A. 41Ramban Street, Jerusalem, Israel.
Introduction In the twentieth century life expectancy has been extended. Youth, energy and initiative are idealized; achievement, success and progress represent important challenges. Few people permit themselves to indulge in thoughts about death. Naturally one tends to reject unpleasant and distressing thoughts. Any speculation on the subject of death is viewed as so fearsome that normally one blocks it out, and when death suddenly forces itself on us, so to speak, we are ill prepared to go through with the experience. The stigma attached to the dying cancer patient is familiar; nurses working on the cancer ward share the common attitude. Research studies carried out in the United States (Abrams, 1966; Olson, 1974; Hobbs, 1969) and in Israel (Antonovsky, 1972) have pointed to the fact that cancer is seen both as malignant and hopeless. There is a widespread notion that of all the causes of death it ranks highest and of course this belief provokes a good deal of anxiety. Studies in the U.S. (Holleb, 1975) and Israel (Antonovsky, 1972) have shown that women tend to delay going for medical checkups out of fear and anxiety concerning the possible diagnosis. Denial is also the most common defence mechanism of cancer patients about to die (Hackett and Weisman, 1964; Haan, 1977). Medical staff on the oncology ward, however, cannot use this mechanism. The staff come face to face with death on a daily basis. A nurse confronted with a dying patient has the problem thrust upon her and must find some way to cope with it. Lately, attention has been focused in the literature on the problems that arise in the treatment of terminal patients, particularly those with cancer (Feifel, 1977; Schoenberg, Carr, Peretz and Kutscher, 1970; 1972). In nursing, overall treatment of the patient and his family has been stressed, and aimed at helping him to regain a sense of mental and physical wellbeing. During her training, the student nurse encounters disease, pain, suffering, and the inevitability of death. For the nursing student, encounters with death are but passing episodes in the framework of clinical care and rehabilitation, and these usually take place when she is assigned to a ward of chronic or cancer patients. 47
48
LEA f3AIDER AND SARAH PORA TH
In nursing literature, the seriousness of the problem is recognized (Quint, 1967; Epstein, 1975). A conflict rooted in the conception of the nurse’s role is uncovered, revealing a wide discrepancy between the student nurse’s image of her future role and the function she performs in reality as she cares for terminal patients. As stated by Craytor et al. (1977): “A task unique to the nursing profession is to assist the individual in sickness or in health to independently maintain habits which contribute to good health or its recovery; functions which he would be able to perform without assistance if he had the strength, the willpower or the knowledge required; and to do this in a manner which would permit him to achieve independence as quickly as possible.”
The nurse in an oncology ward senses the unbridged gap which lies between her professional training and the inherent meaning of terminal patient care. Awareness that one cannot realize professional goals is a link in a chain of frustration hastening fatigue and all the accompanying manifestations of anger, aggression, malaise, and in the end, escape. The nurse feels helpless when relating to patients .who are about to die. The emotional problems she must face involve not only the patient but also his family, other staff members, and above all, herself. Unrelenting focus on patient needs is the hallmark of the nursing profession. This makes great emotional demands on the professional, added to the physical strain inherent in such a commitment. Researchers observing service-oriented professionals have found that the unceasing mental pressure. gradually exhausts the individual’s resources, interfering at times with daily functioning and even precipitating a more serious crisis (Maslach and Pines, 1978; Pines and Kafri, 1978; Maslach, 1976). This phenomenon can be seen in a variety of guises. The nurse may gradually lose interest in her job or even in the profession, transfer to a less ‘threatening’ ward, or drop out altogether. Those who do stay often develop feelings of resentment aimed at colleagues and a hostile attitude towards the patients. Rather than take initiative, assume responsibility, and manifest concern as she had once done, she evolves a very different attitude-submission: to routine, to indifference, to neglect. The framework of her job puts the nurse under stresses which may affect her performance: lowered standards, lateness and absenteeism, illness, and staff quarrels result as they serve to perpetuate the organizational pressures. Behavioural responses are mutually aggressive while levels of controlled and released anger rise. Symptoms of personal exhaustion develop. Thus, providing psychological support and feedback to nurses who work with dying patients is of vital importance for their emotional stability, professional motivation and performance, and awareness of the emotional complexity of their role. This conclusion was reinforced from several sources related to the first author’s work as a staff psychologist in the Oncology Department of Hadassah Hospital in Jerusalem: (1) individual contacts with the nurses of the Department, in which they spontaneously voiced their dissatisfaction, anger and frustration with their work; (2) the impression of the ward physicians that an unusually high level of tension existed among the nurses; (3) the realization that the nurses did not have any support for, or feedback from, their work in the Department; (4) personal conversations with the head nurse about the high turnover rate on the ward and also discussion of other ward problems. Group work with n&es
The first author therefore suggested to form a group to promote the following aims: to facilitate communication among the nurses themselves; to share, in a group context,
UNCOVERING
FEAR: GROUPEXPERIENCE
OFNURSES
INA
CANCER
WARD
49
the common experiences of the nurses, i.e. dealing with cancer patients and with the pressure of work; and, most important, to unmask the nurses’ fears about death and expose the paradox of nurses who know they cannot cure their patients. In 1977-78, 20 group sessions were held, led by the first author as a psychotherapist, assisted by a senior psychiatric nurse (the second author). The sessions were held in the Oncology Ward of Sharett Institute, part of the Hadassah University Hospital. On the average, 6 nurses, 3 of whom are registered, care for 30 inpatients. The patients stay on the ward anywhere between 2 weeks and 5 months; relapsed cases are readmitted to the ward for additional treatment. There are no restrictions on family visits. The patient’s family may eat and even sleep on the ward. As a result, the nurses get to know not only the patient but often the entire family. From November 1977 to June 1978, we met weekly on a regular basis. The time was adjusted to fit the work schedules of the nurses. There were no meetings on holidays. Each session lasted from one to one and a half hours. Nurses raised the issues and the leaders acted as facilitators for open discussion, supporting the nurses when they expressed intense feelings or manifest pain. We dealt mostly with day-to-day matters produced by the work situation while emphasizing those hidden elements in interactions that one tends to overlook. We decided at the onset to meet for about 6 months. An average of six nurses took part in the meetings, though the number varied from four to twelve in any given session. Group process Inception. Making use of the group process, we attempted to show the nurses how they tried to protect themselves from the feelings of anger, fear and frustration brought on by the contradictory nature of their role. The oncology nurse must adjust her function, shifting the emphasis from cure to care, and realize that even care may provide only partial relief from suffering, not its remedy. At the onset, the group identified two discrete approaches to the nurse’s role. The ‘old’ nurses (who had been on the job for one or more years and included two nurses with 8 and 12 years’ experience) approached their work on the ward pragmatically, claiming that only if they neutralized their expressive-affective reactions could they hope to function adequately in the anxiety-provoking, frustrating and threatening environment referred to as the ward. The ‘new’ nurses (new on the job and/or in the country) maintained that in the absence of cure, technical efficiency as a criterion for good performance was out of place and felt that the emphasis ought to be on seeking expressive modes for relating to the dying patient, though such an open and vulnerable position involved real psychological hardship. At the same time, all the nurses accompanied this clear-cut distinction with a common expression of anger and isolation, and felt that they were unable to share their highly emotional but frustrating experiences with one another. The new nurses attributed the overwhelming emotional experience to insecurity and lack of experience and so were ashamed to share it with the other nurses. The old nurses, similarly inhibited, judged their emotions inappropriate in the well-trained, efficient nurse. Both groups of nurses felt alienated and alone. New nurses saw the more experienced nurse as distant, even arrogant, and not to be approached. They described what they did with their built-up tension, how they let it out on their families after work and so extended their work-related frustrations to the home sphere.
50
LEA BAIDER AND SARAH PORA TH
The durses also sought an external target for their mounting anger and found that certain staff members, a type of patient, rules and regulations were easy prey. Most of the time they could not justify their rage objectively, as it stemmed from the subjectively felt isolation and fear that pursue nurses at work. Attempts to externalize anger were followed in the sessions by an emphasis on open discussion of death-that of the patient and their own. This shift occurred once the first phase, which lasted about two months, had ‘legitimized’ free expression of the forbidden feelings of anger and fear. The nurses showed ambivalence in their reaction to patients’ imminent death, alternately approaching and avoiding contact. Every encounter with the patient or his family was like looking death in the face and induced avoidance behavior-until the next time. Subsequent encounters increased the nurses’ involvement and identification with the patients and with the families undergoing anticipatory mourning. It became more and more difficult for the nurses to separate professional roles and private feelings. As one nurse explained: “I could not just go on with the daily routine, giving infusions and taking his pulse, his temperature, blood counts. He always smiled and had an encouraging word for me. Can you imagine? He was trying to lift my spirits, make me feel that I could really help him. Every time I left his room I started to cry; not for him but because I saw how powerless I was, and out of fear. I never told this to anyone. I met his whole family, wife, four children, and other members of the family who came to visit. I talked with them as if they had been my own family. When there wasn’t too much to do on the ward, I would take the children for walks around the building or in the grounds. Afterwards, Mr. P. couldn’t hear enough about our outing and wanted to know every detail. especially about his children. The best times with him were when the ward was quiet. Then I spent a long time with him and he told me about his youth, work, hopes; not once feeling sorry for himself. He knew he was dying. I am sure that he knew, but I could not bring myself to discuss it with him. I was afraid and I didn’t know what I should say. Then I tried not to think about it, to take my mind off the subject. When he died I asked for three days off. I had terrible nightmares and felt so angry and lost that 1 didn’t want to go back to work ever again.”
Many nurses repeatedly expressed their feelings of anger and frustration at ‘losing’ the patient, as if the patient had been a part of their internal love-object. This feeling was followed by one of emptiness and depression, as they questioned the nature and doubted the significance of their own nursing roles. Thus, helplessness replaced direction. At this point the nurses began to speak of being afraid of their own deaths. Rather than focus on the introjection of the patients’ deaths, they directed their attention to the problem of introjection as it related to their own mortality. Nurse A: “When I started to work on the ward I had terrible dreams. I saw what death was. I was taken by force to dark and desolate places where there weren’t any people or other living things, and my voice had no sound. I used to wake up screaming. My room-mates told me to go see someone for help but I was embarrassed and didn’t want to talk about it.” Nurse B: “I also had nightmares. I don’t remember them very well; dreams with people I didn’t know. I cried a lot too, knowing each of them was going to die. I thought that perhaps they were patients, though I couldn’t recognize them. On the ward I looked into the patients’ rooms to see if I could recognize any of them from my dreams, but 1 didn’t. It was really strange, and I was very scared.” Nurse C: “I think we all experience this in one way or another, in this line of work. For me, whenever a patient was dying, I imagined how I might feel or react in his place. Even though I always push such thoughts from my mind, I kept catching myself thinking about my own death. I used to think of it as the unspoken curse of life, something that I couldn’t share with anyone. My family and friends think I’m crazy to be working with dying people. They say that it is enough we live in a country where death is all around us.” Nurse D: “it’s true; my friends and family say the same thing, but 1 see a difference. I am not afraid to get on a bus or pass through Zion Square. 1 don’t think about death. But being here and seeing all the patients suffering, day in and day out, and knowing that they will die in any event, makes me not want to suffer, not want to die.” Nurse E: “But there is a difference. In one case it is a hero’s death, you see. In the other case death comes from a disease that people pretend doesn’t even exist.”
UNCOVERING FEAR: GROUP EXPERIENCE OFNURSES INA CANCER WARD
51
This prompted the nurses to exchange common experiences, personal confrontations with death, their own reactions to the deaths of relatives and friends. It was noted that one reason some nurses work in the Oncology Department is to overcome the fear of their own death. Slowly, the group developed a sense of togetherness, mutual caring and sharing. Nurses were caring and open about one another’s experiences. Death, it was felt, was no longer an isolated, individual, shameful thing, but the reality of all. The nurses had to tackle it on the practical level, and cope with it psychologically every day. This growing sense of mutuality gave the group solidarity and cohesion. For the first time the nurses could talk openly about the real difficulties of their work and the best means for coping with them. Now the group could face the constant pall of death’s approach in a realistic way, as part of their daily work. Of course this optimism was unrealistic as well. Essentially the problem was an integral part of their work. The simultaneous wish to cure and to escape could not be resolved. With all, the group gained insight, and respect for the manifold approaches to death. Termination. Meetings were discontinued about 7 months after they had begun, chiefly for administrative reasons. Many nurses left the Department, the group leader was away temporarily, work pressure mounted. Despite this, a more positive, warm, cooperative atmosphere grew among the nurses. After the break, the nurses were reluctant to resume group meetings because of an objectively heavier work load with fewer nurses on the ward, and a subjectively felt need for a breather from the tough issues faced in the group sessions. Little doubt remains that such a stressful work situation demands a steady, supportive framework within the Department. Other professional groups working with inpatients could effectively provide this support (i.e. doctors, social workers, physiotherapists, etc.). Though the nurses were left with a sense of security and protection from the group solidarity which had developed over the last few months of the sessions, this cannot fully counteract the persistent, wearing effect of death on the performance of their professional roles. The nurses wondered whether the physicians had similar feelings; this implies that they had a strong need to understand how doctors cope with the situation. More overt communication between medical professionals can therefore lead to better, more truthful, ways of handling the stresses of their work. Many issues were not even mentioned by the group or were alluded to only by implication. Among these were the matter of competition between nurses and doctors, and among the nurses themselves. Discussion of other nurses’ and doctors’ deaths was avoided, pointing to the nurses’ own continued vulnerability. Avoidance or denial of certain issues implies the urgent need to work through the feelings involved, and each nurse must find her own best way to deal with these issues. Greater cooperation on the part of the administrative sector of the Department is also essential. Conclusion Studies indicate that in frameworks in which the staff received support from colleagues in staff meetings and through controlled staff turnover, they related to the patients more positively, gained confidence in their roles, and were more consistent. Group sessions were particularly useful in helping the staff to socialize, to consult one another, to give vent to their anger and aggression, and to work as a unit (Maslach and Pines, 1979).
52
LEA BAIDER AND SARAH PORA TH
Studies of nurses’ conception of the cancer patient (Crayton et al., 1977) have recommended a revision of the study programs, a change in attitude, and greater willingness on the part of the nurses to face terminal patients. The stark reality that nurses encounter when working with terminal patients requires a total re-evaluation of their task, geared not to curing, but rather to improved care. Training, supervision, and group or individual support must provide them with the feedback and stimulation necessary to appreciate and go on with their unique, valuable work. References Abrams, R. D. (1966). The patient with cancer: his changing pattern of communication. New Engl. J. Med., 274. Antonovsky, A. (1972). The image of four diseases held by the urban Jewish population of Israel. J. chron. Dis. Crayton, K., Morrow, R., Brown, J. and Fass, M. (1977). A study of nurses’ views and perceptions related to cancer care, cancer patients and cancer nurses. University of Rochester, New York (unpublished). Epstein, C. (1975). Nursing and the Dying Patient. Prentice Hall, Englewood Cliffs. Fiefel, H. (1977). New Meanings of Death. McGraw-Hill, New York. Haan, N. (1977). Coping and Defending. Academic Press, New Yom. Hackett. T. P. and Weisman, A. (1964). Reactions to the imminence of death. In The Threat of Impending Disaster. Grosser et al. (Eds.). M.I.T. Press, Cambridge. Henderson, V. (1966) The-Nature of Nursing. MacMillan, New York. Hobbs, P. (1969) Merseyside survey of public opinion on cancer. Med. Officer, 121. Holleb, A. I. (1975). Women’s attitudes regarding breast cancer: results of the Gallup Poll. In Early Breast Cancer: Defection and Treatment. H. G. Gallather (Ed.). John Wiley, New York. Kafry, D. and Pines, A. (1978). The Experience of Tedium in Life and Work. The University of California, Berkeley. Maslach, C. (1976). Burn out. Humon Behav. 5. Maslach, C. and Pines, A. (1978) Burn out: the loss of human caring. In Experiencing Social Psychology, A. Pines and C. Maslach (Eds.). Random House, New York. Olson, K. (1974). Cancer and the patient. Ann. intern. Med. 81. Quint, J. C. (1967). The Nursesand the Dying Patient. MacMillan, New York. Schoenberg, B., Carr, A., Peretz, D. and Kutscher, A. (Eds.) (1970). Loss and Grief: Psychological Mmagement in Medical Pructice. Columbia University Press, New York. Schoenberg, B., Carr, A., Peretz, D. and Kutscher, A. (Eds.) (1972). Psychotogicut Aspects of Terminal Cure. Columbia University Press, New York. (Received 2.4 June 1980; acceptedforpublication
30 June 1980)